GI problems I - Ow

Question 1

What is normocytic anaemia

Answer 1

Response to inflammation (reduced bone marrow activity)
May be due to bleeding as well but less of a factor
- Acute bleeding can drop Hb without change in MCV
- Chronic bleeding can drop Hb but usually MCV falls due to iron deficiency
Low albumin and high ferritin
- Acute phase reaction

Question 2

Describe chrons disease

Answer 2

At any point of the GI tract (commonly ilium and colon)
Discontinuous (skip lesions, may spare rectum)
Can cause deep ulcers and cobblestone appearance
Transmural inflammation
- Starts as small ulcers on mucosa
- Progresses to deep penetrating ulcers with fissuring
- Mucosa swollen cobblestone appearance
Granulomas my be present but not required for diagnosis
Made worse by smoking
Different behaviours e.g. inflammatory, fistulising, structuring, perianal

Question 3

Ulcerative colitis

Answer 3

Colon only
Continuous inflammation starting at the rectum spreads proximally
Shallow ulcers
Mucosal inflammation(diffuse and regular)
Smoking is protective
Inflammatory
No macroscopic inflammation except in severe disease

Question 4

Churns disease presentation

Answer 4

Depends on the part of the GI tract involved and the clinical subtype
Inflammatory, structuring, fistulising, perianal

Question 5

Chrons disease

• Colitis?
• ileitis?
• Gastritis / duodenitis?

Answer 5

• Diarrhoea, bleeding
• Abdominal pain, typically at least an hour or so post prandial
• Dyspepsia

Question 6

Churns disease

- Stricturing

Answer 6

• Abdominal pain and distention
• Vomiting
• Bowels not opened

Question 7

Chrons disease

- fistulising

Answer 7

Fistula is an abnormal connection/ tract between the gut and another organ / vessel

e. g. small intestine and skin
- Small intestine and small intestine
- Rectum and vagina
- Oesophagus and trachea

Question 8

Chrons disease - perianal?

Answer 8

Perianal access
Perianal fistula
Anal fissure

Question 9

UC: clinical?

Answer 9

Diarrhoea, bleeding 
Frequent bowel motions and urgency 
Abdominal discomfort 
Fever, malaise, weight loss (constitutional symptoms) 
Blood tests: Raised ESR/ CRP, platelets

Question 10

Toxic megacolon in UC

Answer 10

Inflammation in the mucosa extends into the smooth muscle layer, inflammatory mediators released including nitric oxide, NO inhibitor of smooth muscle tone, arrested colonic movement leads to progressive dilatation.

Question 11

Common causes of weightless in Chrons disease

Answer 11

Malabsorption
Chronic inflammation –> catabolism and anorexia
Pain and reduced intake

Question 12

Treatment of IBD in general

Answer 12

5-aminosaliclyates (5-ASA) 
- mild anti-inflammatory action 
- Steroids 
- Immunosuppression: Azatriaprine, 6-mecaptopurine 
Biologics (antitumor necrosis factor)
- Infliximab, adalimumab

Question 13

principles of surgery in IBD

Answer 13

Failure of medical treatment 
- resect diseased bowel, colectomy, iliac resection 
Treatment of complications 
- Bowel obstruction
- Perforation 
- Fistula 
- Abscess 

In UC colectomy is curative, in chrons, no cure

Question 14

what are the consequences of resection of terminal ilium

Answer 14

B12 malabsorption
Loss of specialised receptors for B12/ intrinsic factor complex
Reduced Bile salt re-uptake via enterohepatic circulation
Bile salts lost through colon / faeces
= fat malabsorption (steatorrhea)
Bile salts in colon are irritants, stimulate water and electrolyte secretion –> secretory diarrhoea

Question 15

types of rectal bleeding and their presentations

Answer 15

Upper GI: melaena
Lower GI:
Dark rectal bleeding mixed with stools = proximal colon (caecum - transverse, distal small intestine)
Bright red mixed with stools
= left colon
Outlet (haemorrhoids / fissure): usually fresh and on paper, docent usually cause iron deficiency

Question 16

Do you bleed in coeliac disease?

Answer 16

Not usually

Question 17

Thinking about iron definicy anaemia: things to consider

Answer 17

Age and gender:

• Young women without GI symptoms: likely menstrual loss
• Young women with GI symptoms: often needs investigating
• Older women (especially post menopausal) and in all men: always needs investigating

Break it down to:
inadequate dietary intake - vegetarian
Impaired absorption - coeliac disease
Abnormal loss - adverse and occult bleeding e.g. inflammation, ulcers, diverticulitis, cancer, polyps, angiodsyplasia

Question 18

What are the investigative iron studies you can perform?

Answer 18

Serum iron
Iron binding capacity / transferrin
Iron saturation
Ferritin

Question 19

The common differentials to consider with GI problems

Answer 19

Infection 
Coeliac disease 
IBS 
IBD 
Cancer

Question 20

Coeliac serology

Answer 20

First look for coeliac disease
- Needs to be done whilst consuming gluten
IgA tissue transglutamase antibodies
- Preferred
- As these are IgA antibodies result can be falsely negative in people with IgA deficiency
Other antibodies that can be measured
- Disseminated gliadin peptide antibodies
- Endomysial antibodies

Question 21

Endoscopy and duodenal biopsy

Answer 21

Histological diagnosis still considered gold standard
Varying severity of histological changes
Biopsies taken from proximal duodenum

Question 22

Genetics

Answer 22

> 99% of patients with coeliac disease carry either HLA-DQ2 or HLA-DQ8, but these are also present in at least 50% of the general population
SO if positive doesnt help you in diagnosing coeliac disease (because is present in so many other healthy individuals)
But if negative makes coeliac disease extremely unlikely

Question 23

Association with coeliac disease

Answer 23

Dermatitis herpertiformis 
First degree relative with coeliac disease 
Type 1 diabetes 
Autoimmune thyroid disease 
Osteoporosis 
Infertility / recurrent miscarriage 
Unexplained neurological disease 
addison disease 
Sjogrens syndrome 
Down and turner syndromes 
primary biliary cirrhosis

Question 24

Treatment

Answer 24

Gluten free diet 
main sources of gluten 
- Wheat 
- Barley 
- Rye 
Oats 
- Tiny proportion of coeliacs cannot tolerate 
- Beware of cross contamination with wheat